I have noticed that the concept of “self-medicating” is becoming a popular way to view substance use and addiction. The term self medicating means that a person who is using, is doing so to manage a different underlying condition. I see and hear it referenced by patients, families, articles, and among professionals. This is a delicate topic, because, when we remove the concept of self-medicating people are left with potential addiction. Viewing addiction through the lens of self-medicating protects us from having to view the person’s behavior as addictive and thereby, sometimes, less frightening.

Self-Medication As A Part Of A Dual Disorder

I was recently at a community meeting with the Partnership for Change here in MN. Myself and another colleague were asked to speak on substance abuse as well as dual disorders. As it does with dual disorders – the term self-medicating showed up. Myself and the colleague of mine, Dustin Chapman from U of M / M Health, both emphasized the importance of dropping such language. Dustin provided an eloquent description of what goes on in one’s body when substance use is present.

Dustin described the body wanting to maintain homeostasis at all times. Clarifying that when someone is using for long periods of time they are in and out of a state of homeostasis and when they are using they are in homeostasis. He explains, “When a person is abusing substances, eventually the brain becomes dysregulated. This means that the brain is no longer functioning the way it should. Homeostasis is the brain’s normal state of functioning. This is a state the brain strives to be in. With substance abuse, the brain begins to shift it’s self-reliance to achieve homeostasis to the chemical. In time, the chemical no longer artificially does this. But the brain has “re-wired” itself to accommodate the drug. So when we experience depression, anxiety, fear, grief, elation etc., the brain now relies on the drug to achieve balance. It craves the drug it has come to depend on to regain normal functioning even though the drug may no longer accomplish this. To the outside observer or even to the substance user themselves, this appears to be using to self-medicate feelings when actually, it’s the brain trying to achieve and maintain a normal state of balance.”

So- with this thinking, I am sure we are all going- wait wouldn’t that be self medicating?? For a person dealing with substance use, their body wants to continue to use to feel high, or normal, not to avoid an emotionally distressing feeling. Yes, avoiding feelings also happens too, but if you were to use something regularly, it will become a part of your system, not a part of “feeling better.” When I drink coffee I want to wake up- without it, I am miserable, lethargic and cranky. I love coffee- but I also hate the effects of not having it. So if we look at this as effects, withdrawal and tolerance (addiction) none of these things have to do with “self-medicating” they have to do with maintaining a balance- homeostasis.

Linking Mental Health Problems To Addiction

When we begin to link depression, anxiety and other forms of mental health problems to addiction, we also have to look at the impact of those disorders on the overall system. Depression or any other mental health disorder can perpetuate an addiction or substance use disorder, but will not simply be the reason behind the addiction. So yes, when people are depressed, or anxious they want some relief and for some people they turn to food, drugs or something else- but if we term it self-medicating- not addiction, we end up thinking… well if I were to only get rid of the driving force (depression, anxiety etc) then I would no longer feel like self-medicating and I would be cured of this addiction! Wrong. When we think of it this way, we forget that addiction is a powerful thing, and unfortunately, when you use enough of one thing, your body starts to rely on it, and a high is no longer a high and you need more to function- that has nothing to do with depression or anxiety, that has to do with homeostasis and addiction. Dustin also chimed in to say, “we must also remember that drug use is the main cause of the substance use disorder [not mental health]. The individual must also be taught, counseled and self-directed on the effect of the drugs on their brain and their personal issues.”

Removing the substance we can then see a baseline, is this person depressed, anxious etc due to substance use?? Or did they have depression to start? That is good information to know, but again, managing the mental health disorder will not cure a pattern of substance use, because a pattern of substance abuse is caused by substance abuse. If the substance use is not tackled you will really struggle to treat the mental health disorder. It is best to treat both at the same time, but treating a mental health disorder with the on-going problem of intermittent or regular substance use will interrupt progress and change the person’s emotional baseline again. I should also note that a lot of the time, we see people who experience remission in depression or other mental health disorders when they stay sober. Last, Dustin also emphasized that, It is important to realize that the substance use wiring does not go away. It is always there and can become dominant in situations of extreme emotional distress or elation. This is why a strong recovery support system is vital. Emphasis on new or alternative recovery engagements may hasten new, healthy wiring to take place; re-awaken dormant, healthy wiring and allow for the healthy re-development of brain functioning.”

Addiction: An Important Piece Of The Puzzle

In summary, the concept of self-medicating is a dangerous way to think about the underlying driving force behind substance use. We will miss the important piece of the puzzle, the addiction. I am hoping that this was helpful for people attempting to understand the concept of self-medicating and the potential implications that it has on a person’s treatment. As always, let me know your thoughts!